Transformational Change

Leading Change in a Complex Health Care System

We often hear how timeless the principles of leadership are. However, across industries, today's successful leaders are quick to point out how radically things have changed and how much more challenging leadership is in the present day. Often operating in a bewildering new environment devoid of certainty, where the speed of change is unprecedented and the dynamics of interrelated issues are more complex than ever, many leaders are often left feeling confused.

Thefuture will be confusing.jpg The astonishing speed of change and the seemingly endless "shots across the bow" -- those surprises from external sources and internal crises that point to both the need for or the results of change -- require agility, the ability to adapt, and skills and instincts to react very quickly. Old theories and skills are less reliable in this new world of change. Ideas are vital yet unpredictable, simultaneously stretching creativity, innovation and the boundaries of thinking and expectations.

The speed of change and unprecedented waves of new knowledge create an enormous pressure to be constantly aware and available, and to build new strategies to manage the flow of information. Staying focused on the immediate practical concerns, while continuing to articulate and maintain a vision for transforming the organization to meet changing demand, requires the ability to switch mental gears quickly.

Leading change is a complex task that requires the skilled attention of leaders at every level of the organization. Increasingly, it is the single most important element of organizational success. But it is not easy, and failure rates are high. Our organizations are built for stability, with structure, policies, procedures, roles and responsibilities, training and reward systems that embed this rigor in every role. The stability is so engrained that it becomes virtually impossible to think about other ways of being and doing, and even more difficult to get people to act on changing our ways. This is a critical part of the challenge of change: Unfreezing what is and refreezing at a new, different and higher level of performance.


What Leaders Need

Increasingly, leaders need to view the world through two lenses: a telescope to evaluate opportunities for the future, and a microscope to examine immediate issues. Nimbly moving between near- and farsightedness, leaders will need to stay close to the front line of care delivery, forcing examination of conventional wisdom and the "way we have always done things."

Health care has reached a critical turning point. Patients and payers are demanding more information, transparency and value. The economics of innovations in technology and service delivery and the society-wide discourse on the future of health care create an inflection point that drives the demand for transformation. A more holistic approach to care, value-based incentives and advances in point of care, diagnostics, behavioral insights, emphasis on lifestyle and behavior modification combined with innovations in therapy and care delivery systems has created an expectation for new partnerships, cutting-edge innovations and superior and reliable outcomes for patients, regardless of the site of care.

It is hard to miss the constant call for transformational change, particularly in health care circles. In an environment of discontinuous and incessant change drivers, pressure for organizations to change continues to ramp up, demanding organizational redesign, new work processes and the creation of new knowledge.

But more than technology needs to change.egg-transformation.jpg This type of discontinuous change shatters existing organizational frameworks and scrambles the relationships we have relied on in the past. Hindsight fails in the face of multiple, concurrent and conflicting changes that arise before we have had time to fully transition from the last change effort.

We have dealt with the topic of change for generations, yet history and the research literature continue to point to the high rate of failure for transformational change efforts. Why is the challenge so great?

Focus on Transformative Learning

A plethora of change theories are based on a body of social science focused on changing the organization, with little attention to the individual people who execute change. What is overlooked is the unique value and weight of the individual as a change agent. But merely creating an environment conducive to change isn't enough to build buy-in (or even better, ownership) for the transformation target.

Collaborating for Transforming Practice will address critical issues of transformational change (organizations) and the transformative learning (people) necessary to sustain a new model for medication management in health systems. Focusing on skills, tools and techniques, building team capacity and individual capability will create the opportunity to expand bench strength for transformation.

Transformational Change in Organizations

Guiding change may be a leader's ultimate test. The ability to reinvent purpose and create a new vision is essential and extremely difficult. Transformational change is more than fine-tuning the status quo with a redesign of systems and processes. Transformational change requires people to reframe how they think about and perceive their roles, responsibilities and relationships. This altering of perceptions about work changes behavior. In this process, the organizational culture -- norms, values and assumptions that guide behaviors -- is fundamentally reshaped. No matter how the transformation is described in process terms (Lean, Six Sigma, TQM, Reengineering or Transformation), the basic intent is to make fundamental changes in how business is conducted in order to cope with new and more challenging market conditions.

time for change-management1.jpg For health care, sweeping changes in the last several years have transformed core concepts of health care systems: organizational structure, traditional responsibilities and service boundaries and the role of leaders at every level in strategic decision making. This broad and sweeping change in how we provide health care services and how we pay for it will require a new generation of leaders and a transformed delivery system characterized by "systemness," increasing standardization, centralization and specialization. The span of interest has moved from an acute care preoccupation to a continuum of care with a new sight line that rewards value over volume.

Value-based purchasing by payers will demand improvements in quality and a shift in focus to population health, utilization management and a reduction in the overall cost and in the cost of each episode of care. These leaders will need to think differently, have a new and broader outlook and perspective that inspires them to move from the status quo to new models of integrated care delivery.

While transformation is a noble and popular health system goal, the literature demonstrates that few transformations -- across many industries -- have been successful and sustainable. Strong lessons have been learned about the process of transformational change and the incremental steps essential to transformation success.



There is a wealth of research on change. While there is some variability in the change models of a host of experts, there is broad agreement on basic steps to transforming an organization, including:

  1. Establish urgency.
  2. Build a guiding team.
  3. Frame vision and strategy.
  4. Messaging and communication.
  5. Navigating bumps in the road to change.
  6. Focus on short-term wins.
  7. Make the change sticky.

Transformational change also impacts and alters the culture of the organization, the design of the care process and the systems of organizational learning as well as talent and knowledge management. This module will explore all of these critical aspects.


Establish Urgency

Change efforts typically start with an environmental analysis of the competitive and market position of the organization; technological trends and drivers; and financial performance, including revenue and margin trends, and emerging market opportunities' potential impact on financials. This assessment clarifies the current state of the environment and hopefully serves as a motivational impetus to convince leaders at every level of the need for transformation. Bad business results can be both a curse and a blessing: The catch people's attention and secure their commitment, but can also potentially narrow the room to maneuver.

urgency.jpg This is thought by many to be an easy phase, but it may not be. Driving people from their comfort zone of day-to-day focus on operations, complacency with past successes, and desire to leap ahead to solutions, combined with the assumption that the existing knowledge of the environment is sufficient, can subvert this very critical baseline phase. Fear of change can play a role, and too often the influence of managers who are not true leaders dilutes the effort and commitment. Strong and committed leaders who are vocal "change champions" can drive the engagement of others and build the potential for success.

One big problem with establishing a true sense of urgency is that it is not a typical or normal state of being in most organizations. Complacency is a much more common state of affairs, especially in organizations that have experienced a high rate of success in the past. Even in bad situations where the need for change may be more obvious, the focus can become mere survival or -- worse -- anxiety, and a false sense of urgency may derail the commitment to change.

In A Sense of Urgency, Kotter describes a single strategy and four tactics for increasing and sustaining a true sense of urgency.

The Strategy

Urgency is best built by creating action that is exceptionally alert, externally focused, and relentlessly aimed at winning. Make progress each and every day, and be sure to engage both the hearts and minds of your people. Constantly purge low-result/low-value activities.


Bring the outside in by connecting the dots between internal realities and external opportunities and hazards. One of the best examples of this that I have seen is a senior operations leader from a premier academic medical center providing backdrop opening comments to an integrated team of pharmacists and technicians charged with refining the vision for pharmacy services transformation. He briefly summarized the fiscal pressures that combined revenues, margins, profitability and capital access and deftly connected the dots to health care reform, federal payments and the inflection point created by the baby boom generation hitting the Medicare system.

This was not news. He could have simply provided a visual with this information, but instead he wove a story that underscored the immediate and longer term implications of this fundamental reimbursement and demographic shift in tandem. In doing so, he used emotionally compelling language, data, people and stories to underscore how critical this change force was and would continue to be, with impact for every individual -- patient and caregiver -- and delivered the message that everyone in that group had an opportunity to impact changes to deal with these facts. More importantly, he left them feeling the obligation to contribute to the solutions. Some other thoughts:

Show urgency every day at every opportunity, such as in meetings, one-on-one interactions, written communication, email, etc. Speak with passion, not with complacency, anxiety or anger. One executive commented that urgency is not demonstrated through the one thing you do, but through the 10,000 things you do every day to reinforce it. This means:

In every crisis there is opportunity . . . so find it. Where possible, make crisis your friend, not the enemy, and use that perspective to build a sense of urgency and to destroy complacency. Be careful, however, because this tactic can backfire. Crises don't always create urgency; they can create an angry backlash instead and, unfortunately, they don't always arrive at a convenient or particularly useful time and form. Crises can be an opportunity, but trying to capitalize opportunistically can be a disaster, so tread lightly.

Find and defuse "no-nos" -- what Kotter refers to as the ubiquitous "urgency-killers." These can include skeptics, who create destructive or counterproductive urgency, or who just want to derail the sense of urgency or extend the complacency with the status quo. Distract or immobilize them with social pressure, but don't make the mistake of ignoring them. Hire well to avoid them, and use creative career counseling to confront this negative behavior when it does occur.

Build a Guiding Team

Major transformational change often starts with one person or a handful of people, but successful change efforts build that coalition over in time. Any worthwhile effort needs a critic. The more powerful the coalition members and their supporters are, the more likely the initiative will be successful, regardless of where in the organization the transformation is targeted. Titles, information, reputation, credentials, expertise and especially relationships count.

Building-a-Learning-Organization.jpg The guiding team does not always comprise only your immediate team members. Consider a patient advocate or guide, key physician and nurse champions and others in the organization from critical partner groups (for example, quality and safety, risk management/mitigation, finance, information technology or other departments). Because this group most likely operates outside the normal hierarchy, you'll need to keep the lines of communication open, build shared assessments of problems and opportunities and continue to build trust with strong communication. The energy that emanates from this powerful guiding coalition is essential to initial success and sustained results.

Collaborative communities encourage people to apply their unique talents within the team, and a strong basis for collaboration is motivation to seek a common purpose. Combining this common purpose with a team structure that supports innovation mobilizes the unique talents of each person, builds agility and fosters efficiency and scalability of initiatives. Knowledge companies -- examples include NASA, Citibank, IBM and Kaiser Permanente -- who have employed this commitment to collaboration have reduced error rates by as much as 75 percent and achieved as much as a 10-percent bump in productivity.

The four pillars of organizational effort are critical:

In "Building a Collaborative Enterprise" (published in Harvard Business Review, July 2011), Adler, Heckscher and Prusak describe how organizations build and advance these pillars of change. They use Kaiser Permanente's set of shared values, illustrated in the company's Value Compass, as an example. The Value Compass articulates how the organization's contributions to organizational success provide key contributions to patients, customers and society. The shared purpose is defined as "best quality, best service, most affordable, best place to work." A brief description of a typical team charge for change, The Total Joint Dance, illustrates how collaborative teams (or communities) build on shared purpose to mobilize the knowledge of diverse contributors and produce scalable business results.

Contributing to the team collaborative effort places an emphasis on interdependence. It goes beyond assigned responsibilities to find solutions to achieve a collective result that surpasses what any individual could do. According to Adler, et al, independence versus trusting in the power of collaboration is a bit like streetball versus NBA basketball: "Streetball is roughhousing, showing off, playing for yourself not the team, and your love of the game. In professional basketball, you may still love the game, but you are not doing it just for yourself or even just the team. Other people are involved, it's a business, and the end game has a different level of significance. You are part of a team, you are committed to the trust that the team working together is better than any individual."

The collaborative team must be focused on knowledge production, flexible creativity and scalable processes for coordinating efforts, and this must all be supported by an infrastructure that values and rewards collaboration.

Framing Vision and Strategy

No vision translates into no transformation. It is nearly impossible to engage the support of those around you unless they can feel and sense the greater purpose they will be working toward. The vision needs to be a stretch, but attainable, and go beyond the numbers to make a dream possible.

vision-and-strategy.jpg Without a vision, transformation efforts can easily drift into a succession of conflicting and time-consuming projects that can take the organization in different and/or wrong directions. Sometimes the resulting confusion and paradoxical commitments actually stall the transformation or stop it in its tracks. Without a solid vision, you may end up with plenty of plans, directives and programs, without the convergence to spark a transformation.

Change strategies are often introduced in fat binders with lots of analysis and data tables for evidence, wrapped in new procedures, goals, schedules and accountability assignments. These can be helpful but only if you have a compelling vision for the future state for which you are aiming.

Kotter offers a useful rule of thumb: If you can't communicate your vision to someone in 5 minutes or less, and get a reaction that generates both understanding and interest, you haven't yet finished honing your vision. If you offer a 30-minute lecture, you may have the seeds of a vision, but the basic elements are still buried too deeply to capture the minds and hearts of all of the people who will be needed to achieve it.

A vision often starts with the ideas of one person and a sketchy draft that may be fuzzy and incomplete. With the help and input of the guiding coalition, over the course of a few months or even a year, the ideas will coalesce. The right words will create the message of a vision that sparks the hope and belief in the potential for a better future.

The vision also serves as the foundation for a shared purpose that builds cohesion and articulates how a group will be positioned in relation to partners and competitors. For Kaiser Permanente, the shared purpose of "best quality, best service, most affordable, best place to work" is more than a vision. These words provide a description of what the people in the organization are trying to do and guide everyday decisions and behaviors in both overt and subtle ways, from top management business strategy, to joint planning between management and labor, to unit-based multidisciplinary teams that identify and define work process improvement. This integrated view of collaboration requires the learning of new skills.

Messaging and Communication

After all the time and hard thought that goes into honing a vision that will spark the flame of enthusiasm and commitment for change, surely the brilliance of the message will be apparent, right? Surely the well-written communication announcing the vision will garner the attention it deserves. The message will be clear and everyone can get to work on achieving it . . . right?

Actually, there are three typical strategies for launching a vision:

So what works best? The most successful communication of vision is not one big announcement, or a well-planned strategy of a dozen reinforcing communications, thoughtfully placed and spaced. Leaders who communicate well build their message into their everyday activities, in routine discussions about practice issues and problems, as part of formal performance appraisal and spontaneous teaching moments, and in financial and budgeting discussions. They point out how the numbers are affected by the factors of the transformation. In every conversation, presentation and chance encounter, they bring the message back to the transformation vision and goals.

what-makes-a-leader-communicate-the-vision_poster_img.jpg Successful change leaders also use every available channel to communicate the excitement of the vision. They turn tedious management meetings into exciting explorations of potential and a dialogue about what could be. They reframe training and development to focus on the critical skills and competencies that will be needed for the change, and they create captivating visual and written messages.

Successful change leaders walk the talk. They demonstrate their commitment to the vision in every decision, action and behavior, modeling the way for change.

Aside from the change leader, there is a need to build a strong collaborative community ethic of contribution, where individuals look beyond their specific roles to advance the shared purpose. As compared to traditional models of community or a free agent model, a collaborative community is organized around shared purpose and is coordinated through collaboratively developed, carefully documented procedures. The diversity of capability within a collaborative team or community is the basis of innovation, and the development of knowledge-based interdependency. Interdependency processes include kaizen; process mapping; formal brainstorming protocols; participatory meeting management and decision making with multiple stakeholders; and techniques that establish explicit, flexible and interactive guides to getting the work done and achieving the shared purpose. Because there is broad involvement in the creation of the approaches, people support what they create. Those at the front line who best know the work issues are embedded in the process, and there is greater accuracy and agreement in role definition, decision points and process definition. Anyone can make a change to the process, but everyone needs to weigh in on the consequences of change to ensure there is full understanding of the impact the change will have on the overall process, both upstream and downstream.

The development of a collaborative community is a long-term investment that is costly and time consuming. But to keep pace with the dynamically changing environment in which we operate, fast innovation requires the full engagement of workers in different functions and at different levels. Mere compliance and cooperation cannot compete with true collaboration that results in the simultaneous achievement of cost and efficiency targets. Everyone's understanding, ideas, insights and "aha" moments are needed for continuous high-quality performance at a lower cost. 


Navigating Bumps in the Road to Change

Transformational change initiatives are typically top-down commitments with senior leaders' ownership and buy-in. Any major initiative requiring resource allocation or reallocation will ultimately depend on senior leadership support.

Change initiatives typically begin with an issue or problem that is brought to leaders' attention to seek approval to deploy a possible solution. With leadership approval, a change leader or point person is typically identified. The change leader will be responsible for information gathering and communication efforts to build support for the change. At this point, the change cycle has been initiated at the senior leadership level: The change has been identified, initiated, and initial training for those involved with the change has begun, signaling the "end of the old" in the leaders' minds. The change clock is now ticking.

But, in reality, the change initiative has not really gotten off the ground. The initiative needs funding before any actual activity begins; a budget cycle delay could slow work on the initiative. Concept communication, planning, team building and engagement, and training all take time as well. Meanwhile, the leadership team is now waiting impatiently for results on their decision, which may have been made weeks or months earlier. "The Valley of Despair and Pity City" figure below illustrates a typical pattern in change cycles.


Typically, as this impatience is conveyed, a new sense of urgency develops within the team. The team might make the mistake of moving more or too quickly and skip steps in the engagement, team building or training processes in an effort to get this change off the ground.

As training progresses, dissonance begins among managers who are not involved in the change team, with reactions like:

Every individual has a change cycle curve, shown in the figure entitled "Leadership Team Change Curve."


The point at which the euphoria and positive expectations for change begins to fade is different for each individual, but there is a cumulative curve that impacts the initiative. The extent and timing of engagement, buy-in and ownership help to shape each individual's curve and to define the tendency to fall into the "valley of despair." Individuals at different levels within the organization and with differing levels of engagement with the change "lose heart" and commitment to the change at different points in time before training takes hold and there is a rise in productivity and achievement of results, as shown in the figure below entitled "Frustration of Change." The change team itself, senior leaders and middle management will feel that frustration at different points in the process, and each frustration wave can have an enormous negative impact on those involved in the change initiative and its ultimate success.


There are tools that can be used to effectively minimize the impact of this frustration cycle, including:

Visit the Leadership Resource Center's Leader's Toolkit for more details on using these tools to reduce resistance and build a stronger foundation for change deployment.


Focus on Short-Term Wins

Transformation takes time, and any transformation risks a loss of momentum if there are no shorter term goals to achieve and celebrate along the path to the end game. Compelling short-term evidence will help keep people from giving up prematurely.

How do we drive the innovative work that achieves transformation, particularly with knowledge workers?

As far back as 1968, when Frederick Herzberg published One More Time: How Do You Motivate Employees?, research has shown that people are most satisfied with their work and most motivated when they are given the opportunity to achieve. Supporting an individual's progress is the best way to motivate, and that is accomplished by providing tools and resources for (in order of significance and importance) making progress in work, recognition for good work, incentives, interpersonal support and clear goals. The satisfaction of achievement is a critical building block in the individual's inner work life. The workday events that ignite passion for work, drive motivation and trigger perceptions of achievement are those that signal a sense of progress in meaningful work. The more a person experiences this sense of progress, the more creatively productive he or she will be over the longer term. Typically, "best days" are characterized by progress in work and "worst days" by setbacks.

There are two typical "triggers" for best-day progress: catalysts -- actions that directly support work, including help or additional resources -- and nourishers -- events like encouragement, compliments, recognition or overt respect. Conversely, inhibitors are events that diminish or actively hinder work, and toxins are events that discourage or undermine progress. Catalysts and inhibitors target the initiative, and nourishers and toxins attack the individual. Setbacks, inhibitors and toxins are rare on "great days." Analyzing workday journals of 12,000 knowledge workers, Amabile and Kramer found that on days when progress was achieved, workers reported more positive emotions, joy and pride in their work. They were also more intrinsically motivated by the interest and enjoyment in the work itself, and their perceptions reflected more positive challenges in their work, sense of supportiveness in team activity and had more positive interactions with individuals and teams.

Progress2-300x231.png Progress is measured along a fairly elastic time line. Major breakthroughs are typically long-term events and relatively rare. Importantly, even relatively minor, incremental progress -- short-term wins -- can trigger greater engagement in work, building creative stretch and productivity, impacting longer term performance. Because the flipside is also true, leaders need to work to minimize the daily hassles that can block daily progress.

Some tips for leaders:

Always create the opportunity for short-term wins by establishing short-term goals, building them into performance and incentive plans, reiterating their importance and creating positive feedback loops. By supporting your people and their daily progress in meaningful work, you achieve two goals: making their inner work life more satisfying and contributing to the organization's long-term performance. Their satisfaction in their work contributes to organizational success.

Make Change Sticky

Stickiness is a reflection of how understandable and memorable your change ideas are. Do they have lastingsticky-tape.jpg impact? And most importantly, can they change opinion and behavior?

Not every idea is "sticky," but if we want to succeed with transformational change, stickiness is essential. Standing up straight, making eye contact and smiling are not enough to make your ideas sticky.

Regardless of the strength of your innovative and creative side -- your right brain muscle power -- attention to detail and forethought can make any idea stickier. The authors of Made to Stick, Chip and Dan Heath, believe that the incremental stickiness can make a difference in your success ratio with transformational change.

For an idea to stick, a few things need to happen. The idea needs to:

So what are the traits that make ideas "sticky?'


Six basic principles characterize sticky ideas:


Simple messages that convey the powerful core of the idea deliver the most critical essence of the idea. Articulating the core concept clearly allows you to lead with that message and pull the listener into more detailed supporting messages.

Simple also means ensuring that the message is compact. Simple, direct and short phrases -- exemplified by proverbs and analogies -- captivate the imagination and the commitment to engagement for transformational change.


An unexpected approach gets and keeps people's attention by somehow breaking the patterns of the commonplace and generic messages that continually surround us. Surprising your audience with a unique message can help pull them into the concept. You can stimulate their curiosity and even build a sense of mystery by gradually filling in missing gaps of information toward a shared purpose.


Even though we often operate in complex and ambiguous situations, our purpose and message needs to be anything but, and the concreteness of your message is a critical aspect of its stickiness. Concrete messages stick because they tap into our existing memories and the schema that organizes it in our brains. Our mental schema is like a Velcro filing repository comprising millions of individual memory loops, organized for quick retrieval, links and connections between loosely tied ideas and concepts. Tying your message into the links of existing knowledge and memory expands the power and impact of your message. Creating a concrete message isn't hard, but it may make the leaders vulnerable to slipping into "abstract speak," generic language that is painfully obscure. The leader may also forget that others don't know what the leader already knows.

We may think we are being concrete, but the very detailed process map we unveil may not make sense to the people on the front line of care delivery. While leaders are asking, "How can I make this map more detailed?" the people may be asking, "How can I get them to follow me to where care is delivered?" Stay close to the details that the care providers know best to ensure that your idea and message is concrete.


The credibility of your message makes it believable and pulls others into belief in its potential success. Details and data-based evidence can increase the credibility of your idea and message. But data and statistics can be bland made-to-stick-successbullets.jpgand go a long way to actually blunting your idea and your message, making it inherently less sticky. Humanizing the statistics, connecting the data to an analogy that immediately connects with the impact of the message is vital to establish confidence in the concepts. External validation, vivid details, or a story to illustrate meaning are all potentially valuable in establishing credibility.


Emotion is a powerful adjunct to delivering your idea and your message. Both the mind and the heart are involved in engagement and building empathy. Empathetic feelings grow from specific and particular experience, more so than from patterns. In the words of Mother Teresa, "If I look at the mass, I will never act. If I look at the one, I will." Moving people to think with their more emotional side than their analytic creates the opportunity to tap into the heart -- the emotions of what they care about and their identity, the person they are or aspire to be. The more transcendent the idea and message, the more likely it will touch others at the higher levels of commitment of achievement (for example, Maslow's self-actualization).

Story worthy

Stories have an amazing capacity to convey wisdom, demonstrate the importance of context and illustrate complex points of argument simply, powerfully and memorably. One powerful story can almost single-handedly overcome the knowledge bias that prevents leaders from finding a quick core message that is compelling. Stories are almost always concrete and simple, and many are unexpected and emotional -- if they are on target with your agenda, the idea and the message. Stories have an amazing power to stimulate and inspire. Spotting the powerful ones in the flow of daily events is a function of awareness and applying them to your idea and message.

IDEO -- the iconic San Francisco design firm -- worked with health-system administrators several years ago to improve health care delivery work flow. Recognizing that the internal mindsets of the clients were "set," IDEO created a video of an emergency room patient with a leg fracture. The video was shot from the perspective of the patient. When the administrators watched the video, they essentially experienced what the patient experienced: Entering, looking for navigation clues, waiting, listening to medical and administrative jargon. Wheeled here, there and everywhere, staring at ceilings. Disembodied voices addressing everyone else but the patient. Long pauses with no sound. The administrators' reaction? They had never imagined or seen the patient's reality.

Stories can enlighten and pull others to the idea and the message.


Made-to-Stick-Chip-Heath-Dan-Heath-unabridged-compact-discs-Random-House-Audiobooks.jpg All too often, it's really tempting to enjoy short-term wins and to believe that the change is fixed and anchored -- prematurely. Huge change efforts take time. If the urgency is not intense enough, the team not powerful enough or the vision not clear enough, the change effort can slow. Declaring victory too soon kills the momentum and the initiative of those at the front line. The change slows, then stops and the old ways creep back into place.

Use the momentum from short-term wins to progress to even bigger problems, extending and amplifying that momentum.

Renewal and change efforts take years, not months. Think about, anticipate and try to avoid the bumps in the road to change.

Stickiness becomes most valuable when it converts to a belief that "this is the way we do things here" and becomes anchored in the culture of the organization. This occurs when people in the organization see and believe that new approaches, behaviors and attitudes do improve performance, and when people are recognized, rewarded and promoted in relation to those new approaches, behaviors and attitudes. Leaders need to be the visible and outspoken change champions, and if the culture is to remain anchored and survive, so do their successors.

Made to Stick offers enormous insight into how to better convey ideas and messages to ensure success in anchoring and sustaining transformational change.


Transformative Learning

It's not the change that does you in, it's the transitions. Change is not the same as transition. Change is situational: new site, new boss, new team roles, new policies. Transition is the psychological process people go through to come to terms with the new situation. Change is external, transition is internal. Internal individual change -- what Bridges termed "transition" -- is at the heart of successful transformation.

transformational change.jpg Most transformational change theorists focus on change systems in the organization, assuming that people can and will change as a consequence.

Transformational learning is a conscious process of examining, questioning, validating and revising perceptions of the world. It is a type of learning that induces more far-reaching change in the learner than traditional learning approaches do. People who have experienced transformative learning are very conscious of changes in their perceptions and their ability to apply new knowledge, skills and ideas.

This approach to learning is centered on critical reflection and critical thinking as core skills that are essential to the fundamental change on which we are focusing.

There are essential phases that involve identifying and challenging assumptions, challenging the importance of our context that has influenced assumptions, imagining and exploring alternatives and showing reflective skepticism. Transformative learning typically begins with a triggering event that prompts an individual to feel inner discomfort or perplexity, then leads to self-appraisal, scrutiny and a decision to either live with the issue of concern or deal with it. Exploration of new ideas, new ways of thinking and acting and the integration of those practices into one's life completes the cycle of learning. The distinguishing feature is critical reflection, with the learner reflecting on the very assumptions that support current beliefs and perspectives. Argyris and Schon describe the process of organizational change and learning:

Organizational learning occurs when individuals within an organization experience a problematic situation and inquire into it on the organization's behalf. They experience a surprising mismatch between the expected and actual results of action and respond through a process of reflective thought and action that leads to restructuring their activities, thinking and planning.

For transformational change to occur at the organizational level, individuals must have a transformative learning experience that totally changes their perspectives and frames of reference through critical reflection. As a result, the individual learner becomes empowered, self-aware, self-directing, newly principled and autonomous. Perhaps most importantly, the individual evolves to a new level of commitment and alignment with organizational goals. At the heart of the shift in thinking is a newly developed ability to understand the potential for more than one future reality and the ability to move from thought to action. Individuals work together and solve real problems with a close focus on what is being learned and how that learning can benefit each individual and the organization as a whole. The learning itself focuses on ideas and concepts from a reflective viewpoint, but also on new skills, tools and resources to support a new way of working. The Dartmouth Institute's Clinical Microsystem training and experiential programs, the ASHP Foundation's Pharmacy Leadership Academy, PGY1 and PGY2 residency programs all provide examples of transformative learning experiences that create the will for change, engagement and empowerment of a workforce that will be essential to effecting change.

Change is different today. It is discontinuous and incessant, which means that we no longer have periods of stability in which members of a team can slowly assimilate and adjust. Strategic partnerships, alliances and mergers tear at the fabric that holds organizations together. New technologies are introduced at a relentless rate. Job security is fleeting at best. We know we need to change what we do and how we do it. For pharmacy practice, that is the focus of the PPMI initiatives to evolve to a patient-centric care model that continually improves. To achieve this level of transformation, the organization has to move to a consistently higher level of performance. Individual and group transformative learning structures a path to that higher level of commitment and performance. Transformative learning presents the opportunity to align team members, to reestablish the context for day-to-day decisions based on critical change factors and drivers, and to drive higher levels of engagement and commitment to the transformation.


Culture of Learning Organizations

learning-iceberg.jpg Organizations don't randomly develop into learning organizations. Very young organizations typically learn quickly and together, but this capacity is frequently lost as structure grows, procedures are developed and individual thinking becomes more rigid.

To remain competitive, working more effectively is essential and inherent to learning more and faster than competitors. The challenges are managing knowledge, understanding the internal and external environments, and finding new and creative solutions that employ the full range of knowledge and skills of the organization. Collaboration, trust, and open and reliable conversation are prerequisites.

While all people have the capacity to learn, the organizational structures in which we function are often not conducive to reflection and engagement. Research on the average level of engagement of employees across many industries reports results that are disappointingly low -- in the range of 28 to 34 percent. It is also fairly common for organizations to lack assessment tools and a good sense of the situations they face. To continue to expand capacity and capability, organizations need to create a fundamental shift of mind set among their people that will create a stronger focus on adaptive learning and generative learning.

Learning Organizations Defined

Learning organizations -- those that have a learning culture -- are characterized by five main disciplines, which were identified by Peter Senge over two decades ago. These disciplines, or "component mental technologies," converge to help people shift from helpless reactors to active participants in shaping a new reality and creating the future. Understanding how to tap people's commitment and capacity to learn at all levels of the organization requires systems thinking, personal mastery, use of mental models, a shared vision and team learning.

Systems Thinking

The concept of learning cultures developed out of a discipline called systems thinking. This is a conceptual framework that allows people who study businesses to understand how things -- parts, people, events -- influence one another within the system as a whole and to see problems as multifaceted. The Leadership Resource Center Primer provides a comprehensive overview of Systems Thinking and Complex Adaptive Systems.

In Senge's Fifth Discipline, he puts systems theory to work as a conceptual cornerstone, thereby forcing our view to the interrelationship between parts as an incentive and as a vehicle to integrate across perceived organizational boundaries. Because we learn best from our experiences but seldom experience the consequences of many of our important decisions, and because we tend to think that cause and effect will be in relative proximity, we typically look for actions that will produce solutions in a relatively short time frame. But these short-term improvements often involve very significant long-term effects and costs. As an example, cost pressures may lead to immediate cuts in training and development. While there may not be an immediate impact that is visible, the longer term impact will often lead to loss of focus, errors, work arounds, engagement and morale.

The systems viewpoint is the longer term view. Building and sustaining a new way to think about work requires mapping overlapping systems and understanding and acting based on systems dynamics. Click below to view a brief video segment by Peter Senge on the topic of Systems Thinking: Navigating webs of interdependence. (5:16)

Personal Mastery

Personal mastery is the discipline of continually clarifying and deepening personal vision, focusing energies, patience and a realistic view of the world around us. It involves competence and skills but goes beyond those to capture a very personal aspect of growth and development, a special proficiency, and a calling to a higher purpose. Personal mastery takes the individual beyond a collection of good ideas to a vision for a better future.

Much of individual learning is acquired through staff training and development, but we can't force people to drink from the fire hose of new knowledge. Research shows that most organizational learning is incidental rather than planned, and it is often lost without the context of anchoring it to daily work and aspirations. An acknowledged part of the leaders's strategy must be to create a culture that rewards individual learning, encourages the pursuit of personal mastery and the practice of it in everyday life, and embeds mechanisms for transferring individual learning into organizational learning in the routine of daily work.

People with a high level of personal mastery live in a continual learning mode. It is a lifelong discipline that fosters new knowledge but also builds acute awareness of personal ignorance, incompetence and areas for growth. These are deeply self-confident people who recognize what they do not yet know and persevere in the journey to continue to learn.

Pursuing personal mastery requires a strong personal vision; the ability to deal with the paradox of the elusive gap between our reality and our vision; and the ability to recognize and deal with the organizational structure as well as the constraints and pressures in the face of our own leadership power, influence and ability to advocate for our positions. Truth, openness and strong sustaining relationships support each individual's pursuit of personal mastery.

So how do you know when you have achieved -- or are approaching -- personal mastery? A few inherent traits are:

Personal mastery is a lifelong pursuit that can begin at any point. Some ways to start are:

Think systematically when you encounter an unexpected or undesirable outcome. Think about what might have led to that outcome rather than trying to find someone to blame. Look at the whole situation, the relationship between the parts, and patterns that might provide clues instead of a snapshot of the moment.

Assess the current reality with a focus on your own assumptions, which might be clouding or altering the shape of the reality you are seeing. Thoughtful reflection on what you are thinking and why can clarify your view of reality in the current space.

Most people enter into discussions with defenses securely in place and, as a result, often have difficulty hearing what others are saying. If we spend the same amount of time to understand others' points of view as we do explaining our own position, we will be able to balance inquiry and advocacy. Probe others until there is full understanding of their point of view, and encourage questioning of all the perspectives on a situation.

With a focus on shared perspectives, finding shared purpose is the next step. We find common ground within the range of perspectives and shared understanding. People with highly developed personal mastery understand that they hold only one piece of the puzzle; only through this type of dialogue will the various puzzle pieces that compose a situation fit together to shape a clear picture of current reality. The more complex and chaotic the situation, the more important this approach is to facilitating the transformation of a situation, an organization or a life journey.

This is truly a personal journey, not a destination for target arrival. It doesn't matter when or where you start, just that you begin at a place where you can sense progress and success.

For organizations to develop a learning culture, they need people with various levels of personal mastery. However, this is a path of personal choice that cannot be dictated. Encouraging people to pursue personal mastery depends on a conducive environment or culture that includes:

Mental Models

The assumptions, generalizations, biases and subconscious influences that shape how we see our world and how we take action are extremely powerful and give us ourMental-model.png individual "leadership repertoire" of responses to many situations. Seldom are we aware of the impact of these assumptions on our behavior. To best employ these mental models, we first need to be aware of them. The Leadership Resource Center module on Influence and Advocacy provides an overview of many of these mental models. Click below to view Robert Cialdini Explains Social Psychology. (5:27)

Awareness of the effects of these assumptions is a start, but the discipline of using them also requires turning the mirror inward to examine our internal pictures of the world we operate in and holding them up to personal scrutiny. In our conversations and negotiations, developing inquiry and advocacy skills helps to expose ourselves and others to what and how we think. It open up conversations to influence, convergence of thinking and new solutions. Fostering this openness transcends internal politics and gaming and more widely involves all of the relevant stakeholders in critical complex issues while still allowing leaders to retain some measure of control and coordination through their influence. Click to view the brief video segment entitled Mental Models: The way we make sense of things. (3:15)

Learning organizations challenge and test mental models -- in particular the organizational "memories" that tend to preserve certain behaviors, norms and values -- to build a more open culture that promotes inquiry and trust. "Finding" and uprooting behaviors that represent unwanted values requires a process of "unlearning," the triple-loop learning described by the theories of systems thinking.

Building Shared Vision

Senge believes that the capacity to hold a shared image of the future we seek is a vitally important leadership responsibility and strength, second only to the ability to engage those around you in the vision. The uplifting value of such a vision is what leads others to experiment and innovate -- to learn -- fostering a sense of commitment to the longer term view. Vision drives people to learn and excel because they want to. Sharing such a leadership vision isn't always easy'; it means exploring shared images of what we envision. These are the "what if's" and "can you imagine's" that galvanize the strength of the organization to act in new and different ways.

The most successful visions are collective -- built on the individual visions of employees at all levels of the organization. The structured top-down vision is often diluted in its dissemination and can be counterproductive. Learning organizations are typically flat and decentralized with strong communication support for feedback loops and double- and triple-loop learning.

Visions are spread through reinforcing conversations -- dialogue. Clarity builds enthusiasm that leads to commitment, and commitment rubs off one to another in the interrelated subsystem parts and people. As people talk, the vision grows. The ability for each individual to act within his or her job role and day-to-day responsibility expands. Excitement builds, and we see new ways to grow, learn and improve. The ability to transcend linear thinking and to grasp systems thinking leads to greater awareness of the constraints of mental models and a new commitment to the openness required to take teams in new thinking directions and achieve the vision.

Team Learning

Team learning accumulates individual learning to identify and share critical new learning for organizational advantage. Learning and knowledge management infrastructure facilitate the creation, acquisition, dissemination and implementation of knowledge throughout the organization.

Team learning is the process of aligning and developing members of a team to achieve the desired results, even when those results were not perceived as achievable. Building on personal mastery and shared vision, the capacity of people to act together (and to want to) creates a potential for new results and facilitates the individual learning of each team member.

Team learning starts with dialogue, the suspension of assumptions and collective thinking, which creates the potential for insights that could not be attained individually. It involves recognizing patterns of interaction in the team that encourage or undermine learning. When dialogue is joined with systems thinking, the discussion can unravel befuddling complexities and focus on deeply hidden structural and philosophic issues and forces. The distractions of interactive style, opinion and personality fall by the wayside.



Creating a Learning Culture

Transformational change requires that organizations improve collaboration and teamwork while also improving individual skills, competencies and capabilities, both of which come back to the need to develop a learning culture. To adapt quickly and intelligently, they need to learn all the time, faster than competitors, leapfrogging on the thoughts of the many smart and learned people who surround us.leapfrog.jpg

Organizations that value learning outperform those that don't by taking advantage of how people learn at work: Employees are most likely to learn what they need to do their jobs better, relying on a preferred personal learning style, at their own pace. Leaders must recognize that while adult learners want to be in charge of their own learning, the transfer and spread of learning knowledge is largely the function of the quality and strength of personal relationships. Knowledge "blows" from one person to another in a culture of learning. The network of relationships supports knowing each person's expertise and, as a result, when each person should be involved in an issue. They have timely access to the expertise of others and a willingness to share learning and knowledge in the safety of a trusted relationship. Learning is not just about gaining new information. Just as important is the connection with people who can help to put new information into a context that makes it usable. This is the essence of how people learn best at work, and the core of a learning culture. In fact, experts believe that learning is the only source of sustainable competitive advantage. Click below to watch a short video segment on Creating a Learning Culture (3:54)

Learning in isolation and failing to share perspectives and institutionalize personal -- tacit -- knowledge that resides in individual minds hinders an organization's ability to adapt, transform and thrive in a challenging, changing environment.

Learning is only one aspect of the complex set of issues that define culture, but it is a driving force in the organization's ability to transform in good times and bad. Shared learning increases the capability to predict market changes, adapt to them and make the most of the resulting opportunities. Every leader can create a learning organization and needs to, but how does one do that?

Get clear

How much do you personally value learning? Unless learning is important to you, it isn't likely that you can inspire others to value it.

Bend reality jpg.jpg As a leader, your behavior influences how others begin. Check your own values and add active learning to your skill set, if it isn't already there. See your world through new lenses. Bend your reality through reading, reflective thinking and dialogue.

You also have to be clear about the core purpose of the work you and your team are doing. What is your aim? Who are your customers and how do you or will you create value for them? When workers are clear about their purpose, they are better able to anticipate issues, make aligned decisions and support transformation efforts. When they are not clear, they don't feel part of that larger purpose, and they will therefore not spend time and energy thinking about innovative solutions for something of which they don't feel a part.

Make sure roles and how they relate to one another are clear. When roles are unclear, workers don't feel empowered to take responsibility and be accountable for growth and change. People bump into each other and cause conflicts that sabotage collaboration. Make sure that roles are supported with the needed competence so that each individual has the confidence to perform at their peak. Clarify the shared challenge to motivate each person to leap forward.

Get Started

There is never a perfect time to start, or a natural starting point. It is unlikely that the stars will align to tell you this is the time. With all of the changes looming over health care organizations, we face messy, undefined, unstructured and unfamiliar problems. Our hindsight can't help us, and it is everyone's job to find new ways to act. Unless you are an active learner, you are not part of the change that is needed. You can continue to concentrate on the problems on the high ground -- the manageable ones that lend themselves to solutions based on what we know from our past experiences -- or you can jump into the messy, confusing problems that defy known solutions but that hold our futures in their resolution.

Start "learning conversations." Every day, we each encounter circumstances that call for bringing people together to learn our way through a challenge or wildly unfamiliarFaceToFaceMeetings.png situation. Some triggers for learning conversations are:

Learn in public, where everyone can see you. Encourage everyone to ask questions, share stories and explain successes -- and failures. Listen to everyone. As you learn, gain new habits and try new approaches to learning, you will set an example that generates momentum. Take small steps for change, test the waters and explore how you can learn from these small wins.

Get Informed

One way to begin the process of creating a learning culture and engaging others in the effort is to conduct a learning culture audit to gauge the readiness and receptivity for a learning culture.

take responsibility.jpg A first step is to use a simple diagnostic to help you assess your organization's strengths and weaknesses as a learning culture and describe characteristics of your organization that encourage or discourage active learning. This high-level audit will begin the process of demonstrating interest in learning and asking tough questions about how your people are dealing with the demand for change. Read the Leadership Resource Center's Leader's Self-Assessments (located in the Leadership Toolkit).

Understand the 7 critical aspects of your learning culture using the Organizational Learning Inventory and the 10 Learning Facilitating Factors that can boost your learning culture. These are described in the Leadership Toolkit, with electronic versions of the tools found in the Leader's Self-Assessments.

One more thought: Communicate. You cannot communicate too much regarding how work is progressing, what problems have been encountered and what is needed from each person. Don't avoid conflict at the cost of open communication. Seek out the views of a wide array of team members, especially if they will tell you even those things you don't want to hear as a leader. Doing so breaks down social and structural barriers that might impede learning.

Get Consistent

After assessing your own energy for learning and the learning climate in your organization, and committing to getting started, you will have sparked a cultural transformation that focuses on learning as decision making. But as long as learning is viewed as the latest new approach in a long string of change attempts, you haven't achieved a learning culture. Cementing learning into the culture will require new ways of asking questions and starting conversations, running meetings, conducting performance reviews ("What did you learn last year?") and building new routines for other critical processes. This will establish learning as "the way we do things around here" -- a vital part of the culture. It isn't the 10 things you do to foster a learning culture; it is the 10,000 things you do, consistently, every day, that speak louder than words to demonstrate the importance of learning together as a fundamental trigger for transformation. Create trust by treating people fairly, without favoritism, misguided competitiveness or cover-ups of failures.

Get Together

Be aware of and foster relationships among the people in your organization. These relationships support learning and the development of context that allows people to best use what they learn. Build your guanxi -- the Chinese term for your personal network. Reach out to those around you to gain new knowledge and learn who has the expertise in your guanxi.pngenvironment. Most often, you don't even have to know them; just having a genuine curiosity about issues of mutual interest and concern can start a dialogue that is beneficial to all.

Know where to go to get the knowledge that you need. Adult learning is as much about building relationships for future needs, understanding and context as it is about the issues you face today. Gaining a view of the perspective of others goes beyond the facts to create a broader view of the whole, not just the system parts. Use new knowledge and perspective to see patterns that might not have been obvious before to generate new ideas. Be intentional about your efforts to step outside the limits of your own thinking.

Think about building a visual map of your personal network (like the one below) to determine where you need to build new or stronger interconnected relationships, networking capacity and inroads into new learning opportunities. Where are your gaps and your best opportunities to invest in new relationships for learning?

Building your learning network often means going beyond your role, your department, organization, profession or industry. Learning opportunities exist everywhere insmepersonal network.jpg your personal and professional life, family, community and any group of learners. Find, use and contribute to them.

It takes what Seth Godin (Do You Zoom, 2011) calls "Instigation Capital": the desire and competency to move forward in a new and different way. In order to do something that is different and makes a difference, you've actually got to do something with what you know. Organizations and individuals who don't leverage learning are wasting capital and impeding progress. They are not doing everything they can with what they know.

So a learning culture is far more than simply hiring and creating a smarter workforce. A learning culture is about finding, creating and applying the "smarts" you've gained individually and collectively to create new value in the marketplace. That takes:

Information from a continual stream of input and feedback. Build an insatiable appetite for the right information about trends, competition, peripheral industries, customer feedback and internal business metrics that matter to predict changes, successes and failures.

Interpretation resulting in a thorough understanding of what information does and does not mean. This requires an endless set of questions that begin with "why is," "what if," and "how might or how else." Answers to these initial questions should be met with more questions, not closed-response answers. Use questions to understand fully what the available information is telling us about our current operations, possible next moves and previously unforeseen opportunities. Interpretation is about evaluating, analyzing, synthesizing and thoroughly comprehending the span of an organization's information and knowledge. It is an iterative and evolving web of questions, connection, process and knowledge that leads to significant insight.

Initiation to leverage information and interpretation to develop and launch new business opportunities, products and services to meet the need of primary and secondary customers. Organizations with learning cultures always want to start something new -- not for the sake of being different, but in the hopes of forging new knowledge. Actually initiating change ideas is often the single ingredient that separates great organizations from merely good ones. In addition to a commitment to learning, there is also a willingness to fail, to be publicly wrong and to learn again in the process.


Taking on the Risk Factor

Risk is an inevitable part of transformational change. You will fail, and it might be small and inconsequential or huge, glaring and public. In either case, how you handle the failure can shape your role as a leader.

Managing risk is quite different from managing strategy. Managing risk demands a mindset that focuses on the negative (threats, weaknesses and failures) instead of opportunities, strengths and successes. Risks fall into three basic categories:

reasons for failure.gif Regardless of the type of risk, leaders must be able to detect the failure early, analyze causes deeply and learn from the experience. It is also critical that employees feel safe admitting to and reporting failures, and it is the leader's role to create that safety net.

We often think of failure as something bad, but it isn't always. It is inevitable (at some point), and sometimes failure can produce knowledge that turns it into a fortuitous, even good, event. We also commonly think that learning from failure is routine, something to assign to a committee to assess. Blaming behavior has come under scrutiny as a less than effective means of dealing with failure. As shown in the figure to the left, on a spectrum of reasons for failure -- from deviance and inattention to uncertainty and testing -- blame should be less the focus than learning for the future.

Preventable failures in predictable operations have received much attention. Atul Gawande's The Checklist Manifesto offers a solution for some of health care's most vexing issues, problems and failures. Lean and Six Sigma programs build continuous improvement from small failures translated into an improvement process that provides a step check review of common practices.

Unavoidable failures in complex systems arise from uncertainty and present as things that have not been considered or ever seen before. Thinking of these events as something negative reflects a real misunderstanding of how complex adaptive systems work; it isn't effective. In fact, rapidly identifying and analyzing these small failures can help to avoid massive failures, because a series of small failures can align in just the wrong way at the wrong time for catastrophic events (see Reason's famous swiss cheese model).

The last category of failure is often categorized as intelligent failures. These occur when there is a need to experiment because we can't know in advance what the results will be in a particular situation when a solution is applied. This occurs in situations we haven't faced before (so hindsight is of little value) and that we might never see again, yet we need to find ways to deal with that situation in that moment. This could be called trial and error, but in reality this is yet another example of trying to find the next best step in the right direction, executing it, learning from it and trying again until we meet with success.

Failure as opportunity is a feature of a learning culture, where leaders develop a clear understanding that knowing what happened -- not who did it -- is what is important when things go wrong. How to do that is sometimes a challenge, so here are some tips:

Frame the Work

Frame the work accurately so that there is a shared understanding of how, when and where failures are likely to occur and why openness and collaboration are necessary to learn from these failures. Keep the focus on why this is critical to your mission, and use leaders at every level of the organization to share the message.

Don't Shoot the Messenger

Bad news, questions, mistakes, or second guessing how "we do things" should not be grounds for a firing squad -- literally or figuratively. Think about and thank the source for the value of the news, and then figure out how to fix it. Blameless reporting continues to be a challenge for most organizations. Take bad news well, and learn from the failure.

Acknowledge What You Can't Know

We can't all know everything, particularly leaders who are not on the front lines of care. Be open about what you don't or can't know, mistakes to which you have contributed, and the work that requires a team to accomplish. Embrace what others can offer.

Open the Doors to Participation

Invite others to the team. Look for ideas. Create opportunities for people to find, analyze and resolve failures -- small and large -- to promote opportunities for intelligent failure (the ultimate learning opportunity). Bringing outliers into the change initiatives -- particularly those vocal opponents -- diffuses resistance and defensiveness and builds affinity and positive momentum for the transformation goal.

 Set Boundaries, Accountabilities and Outcome Goals

When leaders are clear and specific about expectations -- including reasons for failure -- workers feel confident and free to act, even in the face of potential failure. Clearly differentiate deviance, inattention and lack of ability from process-related failures, failures of uncertainty or those associated with higher level intelligent failure. Be very specific about where there is latitude to fail with a safety net and what is outside of those boundaries. Without that distinction, the courage to fail is elusive.


Leading in the Learning Organization

Leadership in learning organizations isn't the same as in traditional organizations.

In the traditional view, leaders set directions, make all of the key decisions and energize the people. This very paternalistic traditional view is based on some assumptions:

The "new" leadership of the learning organization is quite different, and leaders' tasks are at once simpler and more challenging (and important). Here, leaders are designers, stewards and teachers, responsible for building the capability to help individuals expand their thinking, understand the complexity that surrounds them (and its context), clarify a vision for the future, and understand the mental models that serve as the guard rails for individual and organizational breakout thinking. This new leadership subtly moves the thinking of individuals in the organization to more strategic and aligned views of decision making. Inspiring the idea and importance of becoming a learning organization is the first task, and a shared leadership model is a first step.

Leader as Designer

Surely the organization's policies, strategies and systems influence the design, but the leader's influence goes beyond these finite factors. Building the call to action, theLeadingFromMiddleResize.jpg opportunities to learn (both formal and informal) and the will to work together is vital to this role.

Leader as Steward

"Purpose stories" frame the overarching explanation of why leaders do what they do, how they envision the organization evolving and how that evolution fits into a bigger, more future-focused picture. Purpose stories provide the integrating ideas that drive leaders to achieve and give meaning to what they do. Critical to this idea sharing is the notion that the purpose story is not owned exclusively by the leader: Stewardship involves a shared commitment to and responsibility for the vision, not self-interest. This is part of something larger than self. The blending of purpose stories strengthens the vision and commitment as others join, blending ideas, visions, ownership and engagement for the potential of a new future. Telling a story in this way pulls others into the change process to develop a vision that is both individual and shared.

Leader as Teacher

Max de Pree suggests that a leader's first responsibility is to define reality -- help people achieve a more accurate, insightful and empowering view of the world that surrounds them. Explanation, context, links and connections build understanding, confidence and the ability to think through the current situation to develop possible solutions.

Leadership Team Learning Agenda

team innovation.jpg Leaders face all of the same learning issues that any team member does, including alignment around shared vision; the ability to discuss reality without bias; clarity of roles and accountabilities; and methods for capturing, cataloging and accessing collective knowledge. Open dialogue among leaders is critical to transformation progress, but tensions and disagreements often spill into conflict and tension; hence, leaders need to hone especially fine skills for conflict resolution.

Several specific skills, which may not have been part of a leader's past skill set, deserve specific attention.

Shared Vision

While shared vision is a skill needed for any team, senior leaders must master this capability, demonstrating behavior that drills down into every part of the organization.

Assessment and Awareness

Understanding with accuracy what is going on in the organization at every moment is a growing challenge. In most organizations, information gathering systems often evolve in ways that provide limited, incomplete and even biased understanding of reality. Leaders need to define and develop methods to uncover timely and accurate snapshots of critical issues and systems. Increasing the opportunity for face-to-face, two-way communication deep in the organization will provide the honest and complete perspective that allows the leader to monitor the pulse of the organization and its transformational journey.

Strategy as a Learning Activity

Dedicated time needs to be set aside to focus specifically on which of the organization's characteristics need to change to ensure results in the pursuit of business strategies, including reward and information systems, recruitment and retention, performance standards and appraisal systems.

Organizational Change

Mastering organizational change -- both transactional and transformational -- is an essential leader skill set, including design, structure and implementation. A leader has to engage the entire organization and foster commitment so that team members will be supportive of the organizational vision and focused on finding truths to serve as mileposts for change success. Creating an organization committed to a new way of being and a new business concept demands new processes that foster commitment, belief and accountability for the enterprise's change goals, and the ability to maintain line of sight to individual job roles and responsibilities.

Some things to consider:

The leadership team needs to learn to lead together instead of as high-level individual contributors. It can't be adopted from another organization or leadership team because it needs to be invented by the team itself.



The Forgotten Side of Change

Change is ubiquitous and found at every turn in our health care world. These can be changes we make or changes that happen to us, both expected and unexpected. We don't have a choice, except regarding when and where we will make change.

As it becomes increasingly clear that change is not an option, the pace of change is one of a leader's greatest challenges, demanding both innovation and creativity.

With innovation, a team manages to change reality and make something new in the system. To be creative, we need to change our perceptions. We have to break the rules that constrain our thinking so we can get beyond improvement to transformation -- thinking up a new system. In the words of Picasso, "to create you must break." The pioneer leaders of pharmacy who developed the unit-dose distribution concept created a new system; for more than half a century, we have been developing large and small innovations to that system. That innovation has resulted in improvement but does not drive transformation.

Changing reality is called innovation, and it requires action by a team. It is a continuous process that often takes a long time in order to deliver something new to the system. Leaders can be fairly certain of the impact because it is typically measurable. This is a process that is fueled by practical ideas and useful suggestions based on observation, and one that can be carefully project managed.

changeperception2-300x251.png Creativity demands that we change our perceptions about reality, and it requires a lot of thinking. Creativity is a challenge for most people, and many have convinced themselves that they can't be creative. While a stroke of creativity comes to us in an instant, it is a discontinuous process of thinking aimed at envisioning a new system. Brainstorming is integral to creativity, which is fueled by questions, surprises, shreds of ideas that don't quite make a whole concept, and strange side trips of thoughts that may not lead anywhere. The transformational change demand that we face in the health care system demands creativity, and it is time to focus on the second half of change.

Creativity means stepping out of the proverbial box. Sometimes that is hard, but in reality, recent changes in health care financing have taken away the box. Boundaries are bleeding everywhere. Without the silo walls that have constrained thinking for so long, opportunities for creative change are limitless -- as long as leaders don't try to drive transformation with hindsight that is firmly fixed on the way things have been. It is a new world, with a future vastly different from our past, and it will never be the same again.


Where to begin change? Typically, thinking about change starts with questions:

These are simple questions that are not easy to answer in a changing world. Space concepts have been redefined, globalized and cast into the new reality of cyberspace that includes teleworkers, virtual teams and partners, and Skyping. The time pendulum is also confusing. We function in real time, but it is not the same for everyone. For example, CNN clocks only have a minute hand, representing a perpetual motion cycle of time. Past time markers are stretched: Staffing schedules and budget cycles don't always fit the new economy. Time and space metrics aren't as reliable as they used to be.

In the past, we have taken comfort in knowing why things happen. But in this rapidly changing world of health care, it isn't always possible. The speed of change is creating a permanent confusion between cause and effect, causing decision making to be more challenging. Even our perceptions of what is true or false are challenged by the paradoxical situations that surround us. Digital editing, virtual reality and digitalization of information are great breakthroughs in preservation but allow for manipulation. As the pace of change accelerates, what is urgent, important or essential blurs. Our frontiers are disappearing. As it becomes harder to define our initiatives in finite terms of completion, the idea of finishing might be more challenging, especially when we are struggling with where to begin to change.


Our Brains Connect Dots

While the world is changing, the tool that lets us change perceptions -- the brain -- may not be changing quite so quickly. How we perceive the world is governed by hundreds of "laws" that allow us to order our world to understand it. What we think, how we act and how reliable our actions are is based on our perception of what we see. We tend to see objects in their entirety before we perceive individual parts. The wholes are organized around grouping "laws" that deal with our visual perceptions of our surroundings and stimuli. But, these perceptions are governed by biases that we should be aware of.


The Law of Proximity states that when an individual perceives an assortment of objects they perceive objectslaw-of-proximity.png that are close to each other as forming a group. The image at right includes a total of 72 circles but we perceive the collection of the circles to be in groups, specifically a group of 36 circles on the left and three groups of 12 on the right side of the image. This principle is commonly used in advertising and logo development to emphasize associations advantageous to the product.


The Law of Similarity leads us to cluster elements of similar characteristics. The similarity can occur with shape, color, shading or any other commonlylaw-of-similarity.png perceived characteristic. . The figure at right illustrating the law of similarity portrays 36 circles equidistant from each other forming a square. 18 of the circles are shaded dark and 18 are shaded light. We perceive the dark circles to be grouped together and the light circles grouped together forming six horizontal lines within the square of circles. The perception of lines is a result of the law of similarity. This law is more powerful than proximity, but the two work together.

Common Fate

The Law of Common Fate relates to movement, stating that objects are perceived as lines that move along the smoothest path and we perceive elements of images to have trends of motion, assuming them to be on the same path. A feature is not perceptible until it moves. Camouflage as a feature of the animal world is a prime example of this law governing our brain. We cannot see a deer in the forest until it moves. The example at left shows an array of dots with half moving upward and half moving downward, with the result that we perceive the upward moving dots and the downward moving dots as two distinct units.continuity.jpg


The Law of Continuity leads the brain to favor uninterrupted connections over abrupt changes and then to see things that "belong together" in presumed patterns or groupings. Only then does the brain return to the disparate -- newly introduced or unfamiliar -- element(s). Stated differently, we tend to see objects as perceptual 'wholes' if they are aligned within an object. Where there is an intersection between objects, we tend to perceive the two objects as two single uninterrupted entities, and are less likely to group elements with sharp and abrupt directional changes as being one object, or even related, as illustrated in the image at right.



The Law of Simplicity explains the mental preference for the uncomplicated. When faced with different options for interpretation, the first one the mind engages is the simplest. the figure at left, most people see a row of martini glasses, not a row of houses. We tend to simplify images to be regular and orderly, eliminating complexity and unfamiliarity -- the extraneous image -- in order to create meaning. In our attempt to create meaning, we often 'filter out' other important element


Law_of_Symmetry.jpg The Law of Symmetry uses balanced proportions as the key element for identifying the whole of the form. The mind perceives objects as being symmetrical and forming around a central point. When two symmetrical elements are unconnected, the mind perceptually connects them to form a coherent shape. Similarities between symmetrical objects increase the likelihood that objects will be grouped to form a combined symmetrical object. The figure at right shows a configuration of square and curled brackets. We perceive the image in a way that identifies pairs of symmetrical brackets, rather than six individual


The Law of Closure demonstrates that individuals tend to perceive objects such as shapes, letters and pictures as being whole even when they are not. When parts of the whole picture are missing, our perception fills in the gaps to complete the picture. In the figure we see objects that have broken line outlines -- gaps missing from the shapes and images -- yet we perceive the complete whole -- not the broken and perhaps unrelated lines.

These laws and the examples provided clarify is the brain's compulsion to find patterns and coherence in randomness. These perceptual distortions can cause us to jump to conclusions OR to have an aha moment. The point is, we really don't see the world as it is; we see it through the prism of the biases of stereotypes, patterns and paradigms. As a result, our bad decisions aren't necessarily due to a lack of information but more likely due to the way our minds work. Understanding these perceptual biases, helps leaders to be aware of what we might read into a situation.

Stereotypes, Patterns and Paradigms

Stereotypes are a critical brain function that enable us to live and think, providing structure and navigation of a world too complex to absorb as a whole. Stereotypes enable us to form judgments that allow our brains to reduce a few words and complex messages to instant understanding -- a vivid image of the immediate reality. They must be shared broadly among the culture to be categorized as stereotypes, and to endure as popular wisdom and commonly held reality. Health care insurance executives, nurse leaders, movie stars, Libertarians and The Big Apple are stereotypical terms that evoke meaning, images, judgment and response. They are -- by definition -- one step removed from reality, but oh so real in our thought processes.

Patterns are everywhere and even when they are not, our brains create them.

Paradigms may not have the obvious negative implications that stereotypes do, but they are an even greater trap. As knowledge builds, learning does not continue in a linear and continuous fashion. Explanations for some occurrences may not be obvious and, in fact, may conflict with other knowledge and beliefs; hence, the paradox. At that point, thinkers develop a new paradigm -- a replacement of one belief set with another -- defined by Kuhn as a "paradigm shift." Geniuses like Newton, Darwin, Freud and Einstein have articulated paradigm shifts that redirected thinking. Enthoven, Berwick, Wennberg, Bates and others have redirected health care thinking in new directions as we faced paradoxes about our systems that were irreconcilable. Paradigms are self-evident to anyone who steps back, observes the change spectrum and recognizes the discontinuities that are problematic. Paradigms tend to blind us to the changes in the outside world. Only by stepping back, observing and thinking can we redefine our paradigms to account for the unexplainable and indefensible aspects of what we do.

Really Seeing: Beyond Perceptions, Beliefs, Knowledge and Hope

Every time we look at the world around us, we are building perceptions. But as de Brabandere reminds us in The Forgotten Half of Change, the eye is not aUntitled.jpg perfect camera, Forgotten half of change.jpgand who we are and our prior experiences get in the way of a clear lens to distort our perceptions. For example, if you buy a blue car, you suddenly see blue cars everywhere. Learn about a new idea, and immediately everyone is writing and talking about it. Our brains adopt the ballast of bias.

Convictions are also totally wrapped up in our perceptions. We believe what we see, but we also see what we believe; if you believe someone is good, you see goodness, and the converse is true. We tend to -- unthinkingly -- distort our reality to support our beliefs. Beyond our immediate beliefs, what we have experienced in the past forms the boundaries of what we can see in the future. In the figure at right, even though we know the lines are the same length -- and could measure to prove they are the same length -- we see different lengths -- evidence that our brains are not always the reliable sensors we would like to believe.

Thomas Edison was a brilliant scientist and inventor, yet he refused to believe in the advantages of alternating over direct current. Heinrich Hertz, the discoverer of electromagnetic waves could not conceptualize the use of his invention to transmit messages from one point on the globe to another because of his 'knowledge' that waves travel in a straight line and the Earth is round, yet Popov tried anyway and showed that the waves bounced back off the ozone layer, and messages were transmitted. Ken Olsen, CEO of Digital Equipment -- at the time one of the top 3 computer manufacturers -- said in 1977 that "there is no reason to believe that people should one day have a computer at home."

What we hope to be true is reflected in what we choose to see, so we typically interpret ambiguous messages into what we want them to be. Simply, we don't see the world as it is; we see it as we are, with the influences of our prior perceptions, beliefs, knowledge and hopes.

We perceive our world in a unique way, but our brains can mislead us. Every stereotype, prejudice, and idea layers a lens of distortion on our view, changing the clarity of what we see and creating a paradox of strategic vision. Being aware of those distortions helps to keep a leader's vision on target to facilitate the transformational change we seek and so clearly need.

Abraham Maslow -- famous for his hierarchy of needs model -- once said that "When the only thing you have at hand is a hammer, it is very tempting to treat things as though they are nails." If we cannot liberate ourselves from the limits of our perceptions -- our current view of "reality" -- and from the belief that we alone as positional leaders are responsible to create vision, engagement and execution of transformational change from the limitation of a single view of reality, we will be challenged to transform the reality of our current practice to one that is collaborative, patient focused, evidence and value based. We need to make room in our tool box for new ways of thinking, new tools, new approaches and above all a new view of who needs to be involved in the ownership of new ideas for change.